Provider Demographics
NPI:1609921121
Name:BOLLER, CHRISTOPHER GEORGE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:GEORGE
Last Name:BOLLER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15122 85TH DR
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-2510
Mailing Address - Country:US
Mailing Address - Phone:171-873-9392
Mailing Address - Fax:
Practice Address - Street 1:10819 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-1034
Practice Address - Country:US
Practice Address - Phone:718-845-2620
Practice Address - Fax:718-845-9380
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072771-11041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00072771Medicaid
NY072771-1OtherLCSW
NY00072771Medicaid
NY06186Medicare ID - Type Unspecified